Managing Depression in Alzheimer’s Patients

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Experts estimate that clinically significant depression occurs in about 20 to 40 percent of people with Alzheimer’s disease. Individuals with Alzheimer’s have the same right to adequate diagnosis and treatment of depression as any other person who develops the disorder. Treatment of depression in Alzheimer’s disease can improve sense of well-being, quality of life, and individual function, even in the presence of ongoing decline in memory and thinking. There are many potentially effective non-drug and drug therapies available and the benefits of treatment justify the cost.

Features of depression in Alzheimer’s disease

Identifying depression in Alzheimer’s disease can be difficult. There is no single test or questionnaire to detect the condition and diagnosis requires careful evaluation of a variety of possible symptoms. Dementia itself can lead to certain symptoms commonly associated with depression, including apathy, loss of interest in activities and hobbies, and social withdrawal and isolation. The cognitive impairment experienced by people with Alzheimer’s often makes it difficult for them to articulate their sadness, hopelessness, guilt and other feelings associated with depression.

Although depression in Alzheimer’s is often similar in its severity and duration to the disorder in people without dementia, in some cases it may be less severe, not last as long, or not recur as often. Depressive symptoms in Alzheimer’s may come and go, in contrast to memory and thinking problems that worsen steadily over time. People with Alzheimer’s and depression may be less likely to talk openly about wanting to kill themselves, and they are less likely to attempt suicide than depressed individuals without dementia. Men and women with Alzheimer’s experience depression with about equal frequency.

Diagnosis and proposed diagnostic criteria for “depression of Alzheimer’s disease”

The first step in diagnosis is a thorough professional evaluation. Side effects of medications or an unrecognized medical condition can sometimes produce symptoms of depression. Key elements of the evaluation will include a review of the person’s medical history, a physical and mental examination, and interviews with family members who know the person well. Because of the complexities involved in diagnosing depression in someone with Alzheimer’s, it may be helpful to consult a geriatric psychiatrist who specializes in recognizing and treating depression in older adults.

A group of investigators with extensive experience in studying and treating both late life depression and dementia, working under the sponsorship of the U.S. National Institute of Mental Health, has proposed diagnostic criteria for a specific disorder called “depression of Alzheimer’s disease.” These criteria are designed to provide a consistent basis for research as well as to aid in identifying people with Alzheimer’s who are also depressed. Although the criteria are similar to general diagnostic standards for major depression, they reduce emphasis on verbal expression and include irritability and social isolation. To meet these criteria, someone must have, in addition to an Alzheimer diagnosis, a change in functioning characterized by three or more of the following symptoms during the same two-week period. The symptoms must include at least one of the first two on the list — depressed mood or decreased pleasure in usual activities.

• Significantly depressed mood — sad, hopeless, discouraged, tearful
• Decreased positive feelings or reduced pleasure in response to social contacts and usual activities
• Social isolation or withdrawal
• Disruption in appetite that is not related to another medical condition
• Disruption in sleep
• Agitation or slowed behavior
• Irritability
• Fatigue or loss of energy
• Feelings of worthlessness or hopelessness, or inappropriate or excessive guilt
• Recurrent thoughts of death, suicide plans or a suicide attempt

Treating depression in Alzheimer’s disease

The most common treatment for depression in Alzheimer’s involves a combination of medicine, support and gradual reconnection of the person to activities and people he or she finds pleasurable. Simply telling the person with Alzheimer’s to “cheer up,” “snap out of it,” or “try harder” is seldom helpful. Depressed people with or without Alzheimer’s are rarely able to make themselves better by sheer will or without lots of support, reassurance and professional help. The following sections suggest non-drug strategies and medications that often prove helpful in treating depression in Alzheimer’s.

Alzheimer's Non-drug approaches

• Schedule a predictable daily routine, taking advantage of the person’s best time of day to undertake difficult tasks, such as bathing
• Make a list of activities, people or places that the person enjoys now and schedule these things more frequently
• Help the person exercise regularly, particularly in the morning
• Acknowledge the person’s frustration or sadness, while continuing to express hope that he or she will feel better soon
• Celebrate small successes and occasions
• Find ways that the person can contribute to family life and be sure to recognize his or her contributions. At the same time, provide reassurance that the person is loved, respected and appreciated as part of the family, and not just for what she or he can do now
• Nurture the person with offers of favorite foods or soothing or inspirational activities
• Reassure the person that he or she will not be abandoned
• Consider supportive psychotherapy and/or a support group, especially an early-stage group for people with Alzheimer’s who are aware of their diagnosis and prefer to take an active role in seeking help or helping others

Alzheimer's Pharmaceutical approaches

Physicians often prescribe antidepressants for treatment of depressive symptoms in Alzheimer’s. The most commonly used medications are in a class of drugs called selective serotonin reuptake inhibitors (SSRIs). These include;

• citalopram (Celexa®)
• sertraline (Zoloft®)
• paroxetine (Paxil®)
• fluoxetine (Prozac®)

Physicians may also prescribe antidepressants that inhibit the reuptake of brain chemicals other than serotonin, including;

• venlafaxine (sold as Effexor® and Effexor-SR®)
• mirtazapine (Remeron®)
• bupropion (Wellbutrin®)

Antidepressants in a class called the tricyclics, which includes nortriptyline (Pamelor®) and desipramine (Norpramine®), are no longer used as first-choice treatments, but are sometimes used when individuals do not benefit from other medications.

Where can I get more information?

The proposed diagnostic criteria for “depression of Alzheimer’s disease” are described in: Olin, J.T.; Schneider, L.S.; Katz, I.R.; et al. “Provisional Diagnostic Criteria for Depression of Alzheimer’s Disease.” American Journal of Geriatric Psychiatry 2002; 10: 125 – 128. On pages 129 – 141 following the article, there is a commentary by the authors discussing rationale and background for the criteria.

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Reviewed: 03/2006